A matter of time

By JEFF SONDERMAN

November 9, 2003 | 12:00 a.m. CST

Thirty times a day, ambulances roar onto the streets of Boone County. But sprawl is slowing them down as populations push outward. A Missourian analysis shows emergency ambulances are too few and far between, and officials say it will take more money to buy better response times.

Andrew Spain and his fellow paramedics sit in the University Hospital emergency room, making small talk, when their handheld radio crackles: “Medical emergency.” Details follow as they rush to their ambulance, Medic 20, hop in and flip on the sirens.

Spain’s partner grabs a road map and gives directions as Spain tries to balance medical urgency with safe driving. The heavy ambulance corners well but the ride is bumpy.

Spain stretches and snaps rubber gloves over his hands as he approaches the scene. On arrival, he and his partner jump out and pull the medical bags and collapsible stretcher out the back double doors and hurry inside.

This scene plays out more than 30 times on an average day in Boone County.

But there’s a problem.

The ambulance services here are slow to respond to medical emergencies in outer parts of the city and in most parts of the county.

Their goal is to arrive at a scene in under eight minutes. But officials say Columbia’s growth and sprawl over the last decade has outstripped ambulance services’ ability to meet their minimum standards designed to protect the lives of patients.

“There are portions of the community we can’t reach in eight minutes, some of which are in the city limits of Columbia,” said Chuck Leake, a former coordinator and current paramedic for the University Hospital ambulance service.

“We cover a lot of territory with only five emergency ambulances.”

The system is as good as it can be with the limited resources it has, said Ralph Lee, manager of Boone Hospital Center’s ambulance service.

“We want the ambulances to cover the bulk of the population,” he said. “We’re trying to play the odds in order to have ambulances ready where calls are most likely to occur.”

Volunteers from the Boone County Fire Protection District often arrive first at medical emergencies in the county, so they see firsthand how long it takes for ambulances to arrive.

“The response times have always been bad,” fire district Chief Steve Paulsell said. “You can just put so many fingers in the dike, and we’ve been doing that for years.”

A Missourian analysis of response times and ambulance systems found:

The emergency ambulances are too few and too concentrated in location to provide complete coverage.

In Hallsville, Ashland, Rocheport and Sturgeon, more than nine of 10 calls missed the standard of an eight-minute response.

Ambulances never met the eight-minute mark for the analyzed calls in Harrisburg, Hartsburg, McBaine and Huntsdale.

Coverage is almost as poor in some of the fastest-growing areas — the south and west rim of Columbia — and in areas along Interstate 70 outside of Columbia. In parts of these areas, ambulances exceeded eight minutes on more than eight of every 10 calls.

Since 1992, the system has not expanded or shifted ambulance locations to accommodate the large population growth in south and west Columbia and other cities in Boone County.

Response times vary

Two hospital ambulance services share coverage of most of the county. Boone Hospital Center’s goal is to reach 80 percent of emergencies in six minutes or less. University Hospital aims to reach 80 percent in eight minutes or less. For this study, the Missourian used the more lenient standard of eight minutes. But the system falls short even of that goal.

Out of 26,744 analyzed calls, the ambulance services missed the eight-minute mark on three out of every 10 calls, which is below the standard. But that performance was uneven.

Some areas, especially those near ambulance stations, were well-covered. But most other areas had excessively long response times.

“It’s almost ridiculous to say we’ll be there in five minutes,” said Brian Kriete, a former paramedic at University and Boone hospitals. That’s possible for a call on campus, he said, but if it’s a 5 p.m. wreck on Interstate 70, they just can’t make it.

Most of Boone County’s emergencies are covered by five designated ambulances. They are stationed at University Hospital, Ellis Fischel Cancer Center, Boone Hospital Center, and county fire stations in Prathersville and Centralia.

Andrew Spain, left, and Tim McGee wheel a patient into the emergency room at University Hospital on Friday, Sept. 26, 2003. Paramedics routinely transport patients from one hospital to another. (DON FEITEL/ Missourian)

Keeping up with growth

Most of Boone County’s emergencies are covered by five designated ambulances. They are stationed at University Hospital, Ellis Fischel Cancer Center, Boone Hospital Center, and county fire stations in Prathersville and Centralia. But the area’s growth has outpaced the ambulances.

From 1990 to 2000, Columbia’s population grew and shifted from the center to the edges of the city. Some areas, especially in the south and west, saw population increases of more than 50 percent.

In the county as a whole, population grew by more than 20 percent and the number of households increased 25 percent.

“The growth over those (past) 13 years is just phenomenal,” Leake said. “EMS needs to evolve to meet the needs of the community.”

The last time the hospitals relocated ambulances to improve response times was more than 11 years ago on Jan. 19, 1992.

“The community had grown and the services had not expanded to meet the community’s needs,” Leake explained. At that time, the northern and western areas around the city were growing fastest. So the services moved an ambulance to the north, in Prathersville, and west, to Ellis Fischel Cancer Center.

Since then, the city has seen huge growth to the south and southwest. But ambulances haven’t moved to follow that growth. “These EMS units are undoubtedly busier than they were in ’88 and ’89,” Paulsell said.

Leake said the explanation was simple.

“There has not been a public outcry,” Leake said. “The organizations have shown in the past they’ll do enough to meet what the community asks for. If there is an outcry from the community about it, the administration would take a look at it.”

Location matters

Central Columbia, where most of the ambulances are stationed, has good coverage, meeting the eight-minute standard on nine of 10 calls in some areas.

But in other areas — particularly around the southern and western parts of Columbia and along Interstate 70 east and west of the city — ambulances missed the eight-minute mark on more than eight of every 10 calls.

But other fast-growing areas, such as the city’s southwest, are hard to reach.

“The population in the last few years has taken a huge growth in the southwest part of the city,” said Leake, whose ambulances have primary responsibility for that area.

“It’s sometimes hard to reach those areas. It might take you 10 to 12 minutes to get there,” he said.

Looking at the data showing long response times in south and west Columbia, Fire chief Paulsell calls these response times problematic:“To be this close to a medical center and have these problems is disturbing.”Apart from central Columbia, the other well-covered spot is Centralia, where the only non-Columbia ambulance is stationed. That ambulance crew met the response rate of under eight minutes for calls in Centralia eight out of 10 times. In those areas outside Columbia and Centralia, ambulances exceeded the eight-minute mark on more than seven of 10 calls. There were more than 10,000 emergency calls in the last three years in those areas.

Lee said that some of the long response times occur when firefighters or police arrive on the scene first and downgrade the situation to a non-emergency. In those cases, the ambulance might stop rushing to the scene and take a safer, slower pace.

But for most of the county, the problem isn’t how fast or slow the ambulances drive — it’s the distance.

Even at 70 miles per hour, an ambulance can’t travel 10 miles down a highway in eight minutes. It’s a similar problem in outlying parts of the city, where distances are shorter but speed limits are lower and traffic is thicker.

Lack of coordination

Each emergency ambulance has its own zone of responsibility. A 911 call in that zone automatically goes to that primary ambulance — if it’s available. If that ambulance is already busy on another call, one has to come from another zone, which naturally takes longer.

Ideally, when one ambulance is busy, the other four would shift positions slightly to provide maximum coverage to the rest of the county.

But there is no nerve center, no field management that keeps track of available ambulances and tells them to relocate.

“It’s up to the crews on duty to remain cognizant of the status,” Lee said.

Fire district Chief of Staff Rob Brown said that during one of the destructive storms that swept through mid-Missouri in May he had to get on the radio and suggest that ambulances move to the northern county, where the forecast predicted storms would be causing damage.

“It took somebody on our side of the fence to get that done,” Brown said.

Both Brown and Paulsell said they see this lack of field management as a serious loss of efficiency in the ambulance system.

Different strategies

Kriete, the former paramedic, said that in the current system there is no way to reach outlying areas such as Rocheport and Ashland in time.

“The only thing they could do is open up another station,” Kriete said.

Fire district officials also said adding and relocating ambulances is part of the solution.

“We’ve got to get out of the mentality that ambulances ought to be parked in front of hospitals,” Paulsell said.

But Leake and Lee both said there simply was not enough call volume near some of the smaller cities and towns for the hospitals to afford stationing ambulances there. To do so would create extra expenses for vehicles, staff, supplies and maintenance.

Andrew Spain washes the ambulance at the end of the day Friday, Sept. 26, 2003. "It's a pride thing," Spain said. "I dont like putting people in a dirty ambulance." (DON FEITEL/ Missourian)

“It all costs money,” Leake said. “We are limited by the resources available to us and the cost of doing business. Until something changes, until the organizations decide to do something different, we’re at the levels we can afford to be at.”

Lee said that adding stations in other cities is possible, “if those communities are willing to support it.”

Spain, the University Hospital paramedic of nine years, said southern Boone County is one area that needs another ambulance.

“Financially speaking, it’s probably not viable. But this is one of those things where you just have to get past the money,” Spain said. “There are patients who are sick down there (in southern Boone County) just like anywhere else. At some point you have to give and say it’s better for patient care.”

But Spain said he realizes the ambulance service is “part of a financial institution that needs to look at its bottom line.”

The budget constraints of for-profit hospitals make it difficult to find money to support another ambulance crew, Kriete said. A service subsidized by taxes might be less constrained by the bottom line.

“It would be nice if the ambulances in Columbia just combined and were taken over by the city or county and funded by taxes. Then you’re not out there trying to make a profit,” Kriete said.

Because of the high cost of adding ambulance stations, the hospitals are also looking at other, more creative ways to improve response times.

Lee speculated that the hospital might get a better “bang for our buck” by educating the public on how and when to call 911, instead of adding ambulances.

Heart attacks also could be reported earlier, when chest pains or shortness of breath first begin. Less urgent patients could be taught when to get their own ride to the hospital or not to call 911 at all.

The system would also be better if all fire trucks carried paramedics, Lee said.

Firefighters have a Basic-Life-Support level of airway management, including oxygen masks and basic tubing. But, Lee said, neither the city nor the county fire department has IVs or medicines. And neither fire department has paramedics or advanced life support equipment on every truck.

Paulsell dismissed this as an immediate possibility in the county. There is a “significant leap” in expense and training between EMTs and paramedics, he said. The fire district is composed mostly of volunteers, and the cost for training and employing paramedics would be far beyond the district’s budget.

(Don Feitel/ MISSOURIAN)

“We don’t believe that’s the full solution,” Paulsell said. “There’s not enough money there without some help.”

Paulsell said he has discussed improvements to the ambulance system, including stationing ambulances at additional county fire stations, with David Coats, executive vice president of The Hunter Group and current executive director of MU Health Care.

Paulsell said the discussions have been “very positive and constructive” but have not produced concrete action so far.

“I’m convinced that Mr. Coats and his team is ready to improve the system,” Paulsell said. “Many times change occurs when management changes.”